Prevention of Nosocomial Infections and Cost Effectiveness Refined (P-NICER) Healthcare associated infections (HAIs) are a major contributor to increased morbidity, mortality and hospital costs; and, the majority of these occur in intensive care units (ICUs) and many are associated with insertion of an invasive device. Reducing HAIs is an important component of patient safety. Guided by Donabedian's theory of quality, in our parent study in 2007, we surveyed a sample of National Healthcare Safety Network (NHSN) hospitals (n = 289, 66% response rate) and received cross-sectional data on structures, processes and outcomes in 415 adult ICUs. We found few structural aspects (e.g., hospital characteristics) to be associated with device associated HAI rates. We did find that intensity of processes was varied; and, only when an ICU had 95% or greater compliance (e.g., Central Line Bundle elements) with processes were the HAI rates decreased. This work represents a significant contribution to the field. However, with increased HAIs caused by methicillin resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. difficile), state mandated reporting of HAI growing from 3 states in 2004 to 36 states in 2009, and in the process of conducting our study, we have identified a number of gaps that our team is uniquely positioned to inform. Additionally, 20 states now mandate reporting through use of the NHSN. Because of this, as well as open enrollment, NHSN has quickly grown to 2,198 acute care hospitals. In this competitive renewal, a 3-year mixed method study organized into two phases is proposed. The aims are 1) Use a descriptive exploratory approach to qualitatively describe the phenomena of infection prevention, surveillance, and control in hospitals; 2) Assess the impact of the intensity of infection control processes on device associated and organism specific HAI rates in adult and pediatric ICUs across the nation; and 3) Determine the impact of state regulated mandatory reporting on infection control processes and HAI rates. In Phase I, we will purposively sample 12 hospitals from the parent study and conduct in-depth interviews with various personnel (e.g., infection professionals and nurses). These narrative data will be analyzed using an iterative process to identify themes in Aim 1. In Phase II, we will refine our survey based upon the results of Phase I and our prior work. Then, in 2011 will survey NHSN hospitals (n = 2,198) on intensity of infection control processes in ICUs and obtain up to 6 years (2006-2011) of ICU-specific NHSN HAI data from our respondents. The analytic strategies for Aims 2 and 3 include state of the art multivariate methods designed to minimize potential bias and address clustering of data. This innovative study builds upon our well developed relationship with NHSN hospitals, our survey, our current data and our past findings. Results will inform bedside clinicians as well as policy makers across the nation. PUBLIC HEALTH RELEVANCE: Annually, approximately 2 million patients are stricken with healthcare associated infections (HAI) and nearly 90,000 of these patients are estimated to die. The annual hospital cost of HAI is estimated to be over 25 billion dollars. Most HAIs are preventable and it is a major public health problem. Results from this study will inform both clinicians and policy makers; these results also have the potential to improve processes at the bedside and reduce HAI rates.